Self-Ligating vs. Conventional Brackets as Perceived by Orthodontists

Transcription

1 Virginia Commonwealth University VCU Scholars Compass Theses and Dissertations Graduate School 2010 Self-Ligating vs. Conventional Brackets as Perceived by Orthodontists Chase Prettyman Virginia Commonwealth University Follow this and additional works at: Part of the Orthodontics and Orthodontology Commons The Author Downloaded from This Thesis is brought to you for free and open access by the Graduate School at VCU Scholars Compass. It has been accepted for inclusion in Theses and Dissertations by an authorized administrator of VCU Scholars Compass. For more information, please contact

2 School of Dentistry Virginia Commonwealth University This is to certify that the thesis prepared by Chase T. Prettyman, D.D.S., entitled Self- Ligating vs. Conventional Brackets as Perceived by Orthodontists has been approved by his committee as satisfactory completion of the thesis requirement for the degree of Master of Science in Dentistry. Dr. Eser Tüfekçi, Thesis Director, School of Dentistry. Dr. Steven J. Lindauer, Committee Member, School of Dentistry Dr. Al Best, Committee Member, School of Dentistry Dr. Bhavna Shroff, Graduate Program Director, Department of Orthodontics, School of Dentistry Dr. Laurie Carter, Director of Advanced Dental Education, School of Dentistry Dr. F. Douglas Boudinot, Dean of the School of Graduate Studies Date

3 Chase T Prettyman, 2010 All Rights Reserved

4 Self-Ligating vs. Conventional Brackets as Perceived by Orthodontists A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Dentistry at Virginia Commonwealth University. By Chase T. Prettyman, D.D.S. D.D.S., West Virginia University School of Dentistry, 2008 Director: Eser Tüfekçi, D.D.S., M.S., Ph.D. Associate Professor, Department of Orthodontics Virginia Commonwealth University Richmond, Virginia June 2010

5 iii Acknowledgment I would like to thank Dr. Eser Tüfekçi, who supported the idea of this research project and assisted me in writing the thesis. I appreciate all of her hard work and the timely manner in which she returned my thesis drafts. It has been a privilege working with her. I would like to thank Dr. Al Best for analyzing the data and for being a part of my thesis committee. I would also like to thank Dr. Steven Lindauer for his help on my thesis committee and his guidance in preparing the survey. I would like to thank Spencer Dixon for his assistance in collecting data from the many surveys. I would like to thank Dr. Bhavna Shroff for her help and for being a wonderful program director. I would like to thank my co-residents and especially my classmates for making these two years so enjoyable. I would like to thank Cecilia Moncure for being such an outstanding assistant and wonderful friend. I would also like to thank my family for all of the love and support they have provided, especially my wife, Stephanie, for her unconditional love, devotion, and remarkable tolerance throughout this process. The funding for this project was from the Alexander fellowship and the Virginia Commonwealth University Orthodontic Department.

6 iv Table of Contents Acknowledgements... iii List of Tables...v List of Figures... vi Abstract... vii Chapter 1 Introduction Materials and Methods Results Discussion Conclusion References Appendix Vita...47

7 v List of Tables Table 1: Practitioner Characteristics...10 Table 2: Responses by orthodontists on bracket preference for a variety of treatment factors 14 Table 3: Mean bracket preference score for a variety of treatment factors....16

8 vi List of Figures Figure 1: Preferences for SL or conventional brackets for a variety of treatment factors 15

9 vii Abstract Self-Ligating vs. Conventional Brackets as Perceived by Orthodontists By Chase T. Prettyman, D.D.S. A thesis submitted in partial fulfillment of the requirements for the degree of Master of Science in Dentistry at Virginia Commonwealth University. Virginia Commonwealth University, 2009 Thesis Director: Eser Tüfekçi, D.D.S., M.S., Ph.D. Associate Professor, Department of Orthodontics Introduction: Within the past decade, significant developments, new designs, and numerous proposed advantages of self-ligating (SL) brackets have caused them to gain great popularity among practicing orthodontists. The purpose of this study was to determine if there are significant clinical differences between SL and conventional brackets on orthodontic treatment as perceived by practicing orthodontists, and more specifically, if the proposed advantages of SL brackets are evident in clinical practice. Methods: A survey was developed to evaluate how SL brackets compare to conventional brackets when perceived by practicing orthodontists (n=430). The initial series of questions focused on individual practitioner characteristics and the clinician s experience with SL brackets, while the second part of the survey allowed the orthodontists to indicate a preference for either SL or conventional brackets in regard to a variety of treatment factors.

10 viii Results: Most of the responding orthodontists (90%) had experience using SL brackets in clinical practice. SL brackets were preferred for the majority of orthodontic treatment factors, and were most significantly indicated as having shorter adjustment appointments (P <0.0001), providing faster initial treatment progress (P <0.0001), and were the most preferred bracket during the initial alignment stage of treatment (P <0.0001). On the other hand, practitioners reported a stronger preference for conventional brackets during the finishing and detailing stages of treatment (P <0.0001), and regarded conventional brackets as being significantly more cost effective than SL brackets (P <0.0001). Less emergency appointments were also reported with conventional brackets compared to SL brackets (P <0.0001). Despite the perceived overall preference for SL brackets, more than one-third of practitioners no longer use or are planning on discontinuing use of SL brackets. In many circumstances, the orthodontists bracket preference was significantly influenced by the proportion of patients they treated with SL brackets (P <0.0001), the number of cases it took them to become accustomed to SL brackets (P <0.0001), and their average appointment intervals for both SL brackets (P <0.0001) and conventional brackets (P = ). Conclusion: Overall, the orthodontists participating in this study reported a perceived difference between SL brackets and conventional brackets on orthodontic treatment. SL brackets were found to be preferred for the majority of the treatment factors, while there were a few situations in which conventional brackets were preferred. Ultimately, due to the lack of high-quality evidence supporting SL brackets, more objective, evidencebased research is essential in order to evaluate definitively the clinical differences of SL and conventional brackets on orthodontic treatment.

11 1 Introduction Self-ligating (SL) brackets were originally introduced in the early 20 th century and, until recently, did not receive much attention in the orthodontic profession. Within the past decade, significant developments, new designs, and numerous proposed advantages of SL brackets have caused them to gain great popularity among practicing orthodontists. 1 Currently, the orthodontic market is flooded with the promotion of different SL brackets. Unlike conventional brackets, SL brackets have a mechanical device that secures the archwire in the bracket slot, thereby eliminating the need for elastic or wire ligatures. This advanced form of ligation can be accomplished either actively by a spring clip that presses against the archwire, or passively in which the clip or rigid door minimizes contact with the archwire. Manufacturers and advocates of SL brackets have proposed many advantages of SL over conventional brackets. Possibly the most advantageous feature proposed with this ligation method is a combination of reduced friction between the archwire and the bracket along with more secure full archwire engagement. 1,2 Together, these properties have been suggested to allow more rapid alignment of teeth and faster space closure, while maintaining excellent control of tooth position. 1,2 It is believed that with the mechanics of self-ligation, greater arch expansion with less incisor proclination is achieved and, therefore, fewer extractions are required to provide space for tooth movement. 3 Several other claimed advantages of SL brackets include less chairside assistance needed, faster archwire removal and ligation, shorter treatment time with fewer appointments, increased patient comfort, better oral hygiene, and increased patient cooperation and acceptance. 2,4

12 2 The emerging clinical popularity of SL systems has bypassed the research and evidence to definitely support all the proposed advantages. 2 Numerous conflicting studies comparing SL and conventional brackets have caused controversy regarding the treatment effectiveness of the different bracket systems As a result, the validity of the advantages offered by SL brackets is questioned. Multiple studies have clearly shown that SL brackets generate significantly lower frictional forces than conventional brackets when archwires are slid parallel to an ideally aligned bracket slot. 5,13-19 However, this is not an accurate depiction of what occurs clinically. When considering different bracket angulations resulting from either malocclusion or tipping of teeth as they slide along the archwire, the difference in friction between the ligation methods is not as apparent. While some studies reported less friction with SL brackets regardless of bracket angulation, 5,18,19 others found that when tipping and angulation are accounted for, SL brackets produce similar or higher friction compared with conventional brackets. 6,20 With regard to archwire size, it is also claimed that the reduced friction of SL brackets is seen only during the early stages of treatment with light wires and, when heavier wires are introduced, friction is comparable between the conventional and SL systems. 21 To summarize these findings about the effects of ligation on frictional resistance, a recent systematic review concluded that in comparison to conventional brackets, SL brackets maintain lower friction when coupled with small round archwires in an ideally aligned arch. 22 Sufficient evidence, however, was not found to claim that SL brackets produce lower friction with large rectangular wires in the presence of tipping and/or torque and in arches with considerable malocclusion. Theoretically, if frictional resistance is reduced with SL brackets, more efficient treatment due to a decrease in the amount of time to align teeth and close spaces should

13 3 be observed with this form of ligation. 23 One of the first studies on treatment efficiency found that patients treated with SL brackets on average finished four months sooner and had four fewer appointments than patients with conventional brackets. 7 Another clinical study found an average reduction in treatment of six months and seven visits for cases treated with a passive SL bracket compared to those with conventional ligation. 24 Contrary to these findings, an abstract published in 2007 found no difference in total treatment time between cases treated with conventional and SL brackets. 8 In regard to alignment efficiency, a prospective study found no overall difference between the two modes of ligation in the time required to resolve mandibular crowding, although a small difference favoring SL brackets was found in the moderately crowded cases. 25 In similar studies, authors have evaluated several different types of SL brackets on alignment, and none have proven to be more effective at reducing irregularity during the initial stages of treatment than conventional brackets When comparing space closure of first premolar extractions, no difference in the rate of en-masse space closure was found between passive SL brackets and conventional brackets. 30 The results of the previously mentioned studies may reflect the concept that friction is not the most important component of resistance to sliding during clinical treatment. Therefore, even if friction is less with SL brackets, other factors such as binding and notching, that are believed to be similar between ligation methods, may be the major determinants of how well bracketed teeth move along an archwire. 23 One reported disadvantage of the SL bracket systems is the difficulty in finishing patients with ideal torque control due to the greater play of the archwire in the slot of SL brackets. 31 In one study, SL brackets presented with higher torque loss compared to conventional ceramic and stainless steel brackets. 9 In other studies, SL brackets were

14 4 found to be equally efficient in delivering torque to maxillary incisors relative to conventional brackets. 10,32 It was concluded that torque expression was determined primarily by the archwire characteristics, and that the bracket system is of minor importance. 32 When considering arch dimensional changes, claims have been made that SL brackets produce less incisor proclination and labial protrusion than expected with conventional systems, and that more significant posterior expansion without the need for auxiliary expanders can be accomplished. 33 While this idea leads to a potential shift in treatment that entails fewer extractions and more arch expansion, it subsequently raises questions about the stability of results and the consequences and feasibility of long-term retention provided by this technique. 3 Regardless of these claims, studies that have compared arch changes between SL and conventional brackets reported identical incisor proclination and intercanine expansion with both appliance systems during arch alignment. 34,35 While these studies did show statistically greater intermolar expansion with SL appliances of 0.91 and 1.3 mm, these differences are clinically insignificant since molar expansion of 1 to 2 mm only results in an additional 0.3 to 0.6 mm in arch perimeter. 36 Initially, SL brackets were introduced to reduce the time of ligation, especially when only steel ligatures were available. 37 Berger and Byloff 38 evaluated the effect of SL brackets in reducing chair time and found that SL brackets saved 10 to 12 minutes per patient compared with steel ligatures and 2 to 3 minutes compared with elastic modules. In light of this study, if a practitioner does 25 archwire changes in a day, he or she could potentially save one hour per day using SL brackets rather than elastomeric ligatures. Other studies have reported lesser reductions in archwire changes of 1.3 minutes, 1

15 5 minute, and 25 seconds per arch with SL brackets. 7,14,39 It is ultimately up to each individual practitioner to compare these modest reductions in chair time against the increased expense of SL brackets to determine if this significantly contributes to the efficiency of their practice. 37 It has also been claimed that SL brackets produce light, continuous forces that are more biologically compatible, which lead to improved patient comfort during tooth movement. 40 This was supported by a prospective study that compared pain levels associated with SL and conventional systems. 11 Patients with SL brackets reported significantly lower mean pain intensity during the initial seven days of fixed appliance treatment. In another study, patients with conventional brackets were found to experience higher, more intense pain for a longer period of time than those with SL brackets. 41 The pain was mostly constant, as opposed to functional chewing/biting pain with SL brackets. 41 In contrast, Scott et al 12 found no differences in perceived discomfort between the two appliances during initial alignment, and other authors reported SL brackets to be more painful than conventional brackets when inserting larger, rectangular archwires. 26,42 Another proposed advantage of SL brackets is improved oral hygiene in patients undergoing fixed appliance therapy due to decreased plaque retention, since elastomeric ligatures are not needed. 43 In two studies that compared plaque formation and bacteria around the different modes of ligation, less retention of oral bacteria, including streptococci, and fewer bacteria in plaque were found on tooth surfaces bonded with SL brackets compared to conventional brackets. 44,45 Pandis et al, 46 however, failed to show a difference in salivary Streptococcus mutans between patients with conventional and SL brackets, and another study revealed no difference in the development of white spot lesions throughout treatment in patients with the two bracket types. 47 Furthermore, a

16 6 prospective analysis failed to demonstrate an association between the bracket types and periodontal health following appliance removal. 43 This suggests that while bracket type may influence bacterial load during treatment, this effect may not be sustained after treatment is completed. 48 The proposed advantages of SL brackets challenge several aspects of conventional orthodontic thought, and many conservative orthodontists are skeptical of this bracket system. Despite this opposition, the recent widespread use of SL brackets indicates that this technique is likely a viable alternative to conventional methods. 4 However, due to the lack of long-standing evidence on the clinical outcomes of SL brackets, this recent bracket trend does demand further scrutiny. In addition to the need for more sound, scientific evidence, an evaluation of actual clinical observation is essential in attempting to resolve the uncertainty of the claimed advantages/disadvantages and treatment outcomes of SL brackets. The purpose of this study was to determine if there are significant clinical differences between SL and conventional brackets on orthodontic treatment as perceived by practicing orthodontists, and more specifically, if the proposed advantages of SL brackets are perceived to be evident in clinical practice.

17 7 Materials and Methods A survey was developed to evaluate how SL brackets compare to conventional brackets as perceived by practicing orthodontists. The survey consisted of a one-page questionnaire that was primarily designed to target claimed advantages of SL brackets to see if the orthodontists agreed with these claims based on their experience with these fixed appliances (See Appendix for survey). The initial series of questions dealt with individual practitioner characteristics and focused on the responding clinician s experience with SL brackets in their practice, such as How long have you been using SL brackets? and What percentage of your patients do you treat with SL brackets?. The second part of the survey assessed a variety of treatment factors, allowing orthodontists to indicate a preference for either SL or conventional brackets based on their experience and perceived clinical results. Duration of treatment time, discomfort experienced by the patients, and likelihood of extraction treatment were only a few of the factors evaluated in this section of the study. Each survey had a blank section for the respondents comments. Prior to the study, approval was obtained from the Institutional Review Board of the Virginia Commonwealth University Office of Research. The surveys, with addressed postage paid return envelopes, were mailed to 1000 orthodontists under the age of 60 whose names were randomly selected from the AAO s nationwide database with the AAO s permission. A short explanation of the study was provided on the front page of the survey requesting voluntary participation. There were identifying markers on the surveys to trace back individual respondents, which were matched to a coding list at the mailing center in order to maintain confidentiality of the answers submitted. A follow-up

18 8 survey was sent to all the orthodontists who did not return a completed survey with the first mailing. Survey responses were recorded using an Excel spreadsheet. The results were summarized using SAS software (SAS version 9.2, JMP version 8.0.2, SAS Institute, Inc., Cary NC). In analyzing the individual treatment factors from the second part of the survey to determine if there was a preference for either SL or conventional brackets, a scoring of -1 was used for conventional brackets, 0 for no difference, and +1 for SL brackets. Then, a test of whether the average score was zero indicated whether there was a significant preference one way or the other. The level of statistical significance across all of the items was controlled using a Bonferroni correction, where the nominal level of significance was required to be P <0.05/(number of questions) or P <0.05/13 = A multi-way ANOVA was then used to screen each of the practitioner characteristics separately (from the first part of the survey) to determine if they had any association with the overall bracket preference of a practitioner. Statistical significance was kept at P <0.05 for this analysis. Any characteristic found to be significantly related to an overall bracket preference was further analyzed using a repeated-measures mixedmodel analysis to determine its significance on the bracket preference for each individual treatment factor. The same Bonferroni correction (with significance at P <0.0038) was used to correct for multiple comparisons.

19 9 Results Of the 1000 addresses on the mailing list, eighteen were not recognized by the post office as deliverable. Therefore, the survey was mailed successfully to 982 orthodontists, of which a total of 430 (44%) were returned. Of the responding practitioners, 385 (90%) reported that they use, or have previously used SL brackets. Table 1 indicates that more than half of the orthodontists (52%) used SL brackets on less than 30% of patients. The majority of the practitioners (73%) had been using SL brackets between two and ten years, and most (76%) became comfortable with SL brackets after treating less than thirty cases. Overall, there were more orthodontists (65%) who claimed that they do not use SL brackets as a marketing tool for their practice. When comparing appointment intervals of the practitioners, the average interval for conventional brackets was 5.8 weeks (SD = 1.24) versus 7.2 weeks (SD = 1.44) for SL brackets. Therefore, practitioners using SL brackets scheduled an additional 1.4 weeks between appointments, on average, compared to conventional brackets (P <0.0001). Of the 385 orthodontists who responded that they have used SL brackets, 137 (36%) reported that they no longer use them or are planning on discontinuing. The majority of these orthodontists (59%) stopped using SL brackets because they did not see significant enough advantages to justify expansion of inventory and increased costs associated with these brackets.

20 10 Table 1: Practitioner Characteristics Question n % Approximately what % of your patients do you currently treat with selfligating brackets? 0 to 30% to 70% to 100% How long have/had you been using self-ligating brackets? less than 2 yrs to 10 yrs more than 10 yrs 24 6 How many cases did it take for you to become accustomed to self- ligation and feel comfortable using this technique? less than to more than never became comfortable Do/did you use self-ligating brackets as a marketing tool for your practice? Yes No What are/were your average appointment intervals for conventional brackets? 4 to 5 weeks to 7 weeks to 9 weeks or more weeks 2 1 What are/were your average appointment intervals for self-ligating brackets? 4 to 5 weeks to 7 weeks to 9 weeks or more weeks 26 7 If you no longer use self-ligating brackets, or are planning on discontinuing their use, what was the main reason for your discontinuation of self-ligation? (a) I was able to achieve better results with conventional brackets than self-ligating brackets. (b) I did not see significant enough advantages with self-ligating brackets to justify expansion of inventory/cost. (c) I did not like working with self-ligating brackets clinically (bonding issues, ligation technique, etc.) (d) Patients did not like self-ligating brackets. 7 5 (e) other 3 2

21 11 The practitioners preferences for either SL or conventional brackets were assessed by responding to statements regarding a variety of treatment factors which are summarized in Table 2. For example, when considering treatment time, 37% of orthodontists indicated that SL brackets yielded a shorter overall treatment time, and 6% reported that conventional brackets yielded a shorter overall treatment time. The remaining 57% of orthodontists reported no difference in overall treatment time between the two bracket types. Using a scoring of -1 for conventional brackets, 0 for no difference, and +1 for SL brackets, a test of whether the average score was zero indicated whether there was a significant preference one way or the other (Figure 1; Table 3). Using a Bonferroni corrected p-value, it was found that there was a significant preference for SL brackets in regard to overall treatment time (P <0.0001). More specifically, 68% of the practitioners who indicated shorter treatment with SL brackets claimed this overall treatment time difference was two to six months less than with conventional brackets. In evaluating bracket preference, three of the treatment factors had to be reverse scored to demonstrate the actual bracket preference for the situation. These comparisons are marked with asterisks in Table 2, Table 3, and Figure 1. For example, orthodontists were asked to identify which bracket caused more patient discomfort during adjustments. Since the answer actually demonstrated a preference for the opposing bracket type, the score was reversed to demonstrate a preference for the bracket not chosen. This was also done when evaluating the likelihood of extractions and the frequency of emergency visits. Overall, SL brackets were significantly preferred for nine of the thirteen treatment factors, which can be visualized in Figure 1 and Table 3. In addition to a perception of shorter overall treatment time, orthodontists reported that with SL brackets, patients

22 12 present with better oral hygiene (P <0.0001) and experience less discomfort during adjustments (P = ) than with conventional brackets. Furthermore, it was perceived that assistants prefer working with SL more than conventional brackets (P = ), and 64% of orthodontists claimed adjustment appointments are shorter with SL brackets (P <0.0001). In further evaluations, practitioners stated that treatment progresses faster initially using SL brackets (P <0.0001), and for treatment of a crowded dentition, orthodontists reported they were less likely to extract teeth with SL brackets than conventional brackets (P <0.0001). When asked to indicate which bracket was preferred for different stages of treatment, 68% of orthodontists chose SL brackets for initial alignment (P <0.0001) and 54% preferred SL brackets during space closure and anteriorposterior changes (P <0.0001). While SL brackets were reportedly preferred for the majority of the treatment factors, there were others in which conventional brackets were significantly preferred. Conventional brackets were found by 68% of practitioners to be most cost effective and were significantly preferred over SL brackets in this regard (P <0.0001). Also, less emergency visits were reported with conventional brackets (P <0.0001), and the majority of orthodontists (64%) indicated that they preferred conventional brackets over SL brackets during the finishing and detailing stages of treatment (P <0.0001). With regard to long-term stability and relapse potential, no significant bracket preference was indicated by the practitioners (P = ). From all treatment factors combined, the overall bracket preference of an orthodontist was then related to the practitioner characteristics from the initial survey questions seen in Table 1. No significant association was found between an orthodontist s bracket preference and the length of time they used SL brackets (P = ) or whether

23 13 they used SL brackets as a marketing tool (P = ). There was, however, a significant association between bracket preference and four of the practitioner characteristics. These included the percentage of patients treated with SL brackets (P <0.0001), the number of cases required to become accustomed to SL brackets (P <0.0001), and the average appointment intervals for both conventional brackets (P = ) and for SL brackets (P <0.0001). These four characteristics were further analyzed to determine their influence on bracket preference when considering each individual treatment factor. The associations with these four characteristics and each factor are indicated in the right-hand column of Table 2 and explained below the table. For example, when evaluating overall treatment time, the practitioners who preferred SL brackets were those who treated a higher proportion of patients with SL brackets (association A), who quickly became accustomed to SL brackets (association B), and who reported longer appointment intervals for SL brackets (association D). The only treatment factors in which bracket preference was not influenced by any practitioner characteristics were the likelihood of extraction treatment and the frequency of emergency visits.

24 14 Table 2: Responses by orthodontists on bracket preference for a variety of treatment factors Treatment Factor For a given case, the overall treatment time is shorter with During adjustments, patients experience more discomfort with* Patients present with better oral hygiene when treated with n (%) Conventional No SL brackets difference brackets Association 22 (6%) 214 (57%) 141 (37%) (A)(B)(D) 102 (27%) 216 (57%) 61 (16%) (A)(C)(D) 17 (4%) 204 (54%) 159 (42%) (A)(D) Assistants prefer working with 123 (33%) 70 (19%) 184 (49%) (A)(D) Adjustment appointments are shorter with For a crowded dentition, I would be more likely to extract teeth using* Initially, treatment progresses faster with There are more emergency visits with* Long-term stability with less relapse potential is better achieved with Which bracket system is most cost effective 27 (7%) 110 (29%) 242 (64%) (A)(D) 113 (30%) 232 (61%) 36 (9%) 10 (3%) 121 (32%) 250 (66%) (A)(D) 26 (7%) 283 (75%) 70 (18%) 16 (4%) 341 (93%) 10 (3%) (A) 254 (68%) 48 (13%) 70 (19%) (A)(C) Indicate which technique you prefer for each of the following stages of treatment: Initial alignment 69 (18%) 54 (14%) 259 (68%) (A)(B)(D) Space closure/anterior-posterior changes 106 (28%) 68 (18%) 206 (54%) (A)(B)(D) Finishing/detailing 242 (64%) 57 (15%) 81 (21%) (A)(B)(C)(D) Association: Between practitioner characteristics and bracket preferences (A) Practitioners who treated a higher proportion of patients with SL brackets reported a significantly stronger preference for SL brackets. (B) Practitioners who quickly became accustomed to SL brackets reported a significantly stronger preference for SL brackets. (C) Practitioners who reported longer appointment intervals for conventional brackets reported a significantly stronger preference for conventional brackets. (D) Practitioners who reported longer appointment intervals for SL brackets reported a significantly stronger preference for SL brackets. * These items were reverse scored to identify the actual bracket preference

25 15 Figure 1: Preferences for SL or conventional brackets for a variety of treatment factors The bracket preferences are shown as 95% confidence intervals. * These items were reverse scored to identify the actual bracket preference.

26 16 Table 3: Mean bracket preference score for a variety of treatment factors A preference scoring of -1 was used for conventional brackets, 0 for no difference, and +1 for SL brackets, and a test of whether the average score was zero indicated whether there was a significant preference one way or the other. Statistical significance, after Bonferroni correction, was set at p< to achieve an α= 0.05 across all of the treatment factors. *These items were reverse scored to identify the actual bracket preference.

27 17 Discussion Most of the responding orthodontists (90%) had experience using SL brackets in clinical practice. Overall, these practitioners reported a perceived difference between SL and conventional brackets on orthodontic treatment. SL brackets were found to be preferred by orthodontists for the majority of the treatment factors, while there were a few situations in which conventional brackets were preferred. No difference was found in perceived stability or relapse potential between the two bracket types. Despite the perceived overall preference for SL brackets, more than one-third of practitioners (36%) no longer use or are planning on discontinuing use of SL brackets. In many instances, the orthodontist s bracket preference was significantly influenced by the proportion of patients they treated with SL brackets, the number of cases it took them to become accustomed to SL brackets, and their average appointment intervals for both SL and conventional brackets. Significant developments and new designs, along with the ever increasing promotion from manufacturers and advocates, have greatly aided in the rising popularity of SL brackets within the orthodontic community. A previously repeated survey of American orthodontists showed an exponential rise in the use of SL brackets from 8.7% in 2002 to 42.4% in ,50 A more recent journal article in 2009 reported that 75% of the orthodontists surveyed were currently using SL brackets. 51 In another 2009 survey to all US orthodontic programs, 63% of residents stated they are going to use SL brackets in practice, and an additional 30% claimed they might use SL brackets. 52 Only 4% of all responding orthodontic residents reported they are not going to use SL brackets at all. Of the 430 nationwide orthodontists participating in the current survey, 385 (90%) reported they had used SL brackets. It is possible that this survey attracted an increased response

28 18 rate from SL bracket users to whom the topic was of more immediate interest, and therefore possibly more motivated to answer the questions, while those with no SL experience may have been more likely to discard the survey and give no response. As a result, the 90% of respondents with SL experience may be higher than what is truly representative of all practicing orthodontists. Regardless, 137 of these respondents (36%) reported they no longer use or are planning on discontinuing use of SL brackets. Of all the participating orthodontists, this leaves a total of 248 (58%) who currently use SL brackets and plan to continue to do so. From the survey, it appears that most practitioners use SL brackets on either a low percentage or high percentage of patients. This is demonstrated by the fact that 52% of respondents reported using SL brackets on less than 30% of patients, while 33% reported using SL brackets on the majority (70%-100%) of patients. The findings were similar to a 2009 survey of SL bracket users, in which 33% of these practitioners used SL brackets in all their cases and 11% used them in most cases. 51 In the current survey, only 15% of orthodontists, therefore, reported using SL brackets with a somewhat comparable frequency as conventional brackets. Several of the responding orthodontists commented that they use SL brackets only in select cases such as those with high canines or for esthetics in adults to eliminate discoloring ligatures. Overall, the proportion of patients an orthodontist treated with SL brackets correlated significantly with that practitioner s bracket preference. In this regard, it was no surprise that practitioners who treated a higher proportion of patients with SL brackets were more likely to prefer SL over conventional brackets for almost every treatment factor. Most of the responding orthodontists (73%) had between two and ten years of experience using SL brackets. Twenty percent of respondents had less than two years of

29 19 experience, while 6% had used SL brackets for more than ten years. The difference in length of time using SL brackets showed to have no impact on overall bracket preference for the orthodontists. This was surprising, since a practitioner s experience and length of time using a bracket system would be expected to impact their preference for that appliance. The majority of practitioners (76%) also reported that it took them less than thirty cases to become accustomed to SL brackets to feel comfortable enough to use the appliances. More specifically, 38% of practitioners stated they were even comfortable with SL brackets in less than ten cases. In contrast, 11% of orthodontists claimed they never became comfortable using SL brackets. A responding orthodontist stated, Selfligating is a great tool once you are familiar with the system, you know how to use (open/close) brackets, and you are comfortable troubleshooting. Indeed, a significant association was found between a clinician s overall bracket preference and the number of cases it took the clinician to feel comfortable using SL brackets. Practitioners who quickly became accustomed to self-ligation were more likely to prefer SL brackets during all stages of treatment and were also more likely to report a shorter overall treatment time with SL brackets compared to conventional brackets. While manufacturers are constantly promoting new designs and claiming numerous advantages of SL brackets to the orthodontic community, many orthodontists have likewise begun using SL brackets as a marketing tool for their own practice. These practitioners are advertising this new technology and listing the potential advantages of SL brackets to not only patients, but to referring dentists with the hope of increasing referrals. In this study, 35% of orthodontists reported using SL brackets as a marketing tool for their practice, while the remaining 65% claimed they use SL brackets as a

30 20 marketing tool. One practitioner claimed, Patient acceptance is very high with SL brackets because they are considered high tech. Another orthodontist remarked, I personally like conventional brackets for rotational control, but I use self-ligation because my competitors use them. With the potential increase in competitive marketing of SL brackets, practitioners may begin to feel pushed into using these brackets to protect the success of their business. In this study, there was no association found between the orthodontists use of SL brackets as a marketing tool and their overall bracket preference. It has been suggested that SL brackets permit longer appointment intervals than conventional brackets due to their ability to ensure full and secure archwire engagement of low modulus wires. 1 Intervals of eight to ten weeks have been deemed appropriate when using SL brackets. 1 When comparing the appointment intervals of the responding orthodontists, the average interval for conventional brackets was 5.8 weeks versus 7.2 weeks for SL brackets. This average extension in appointment intervals of 1.4 weeks for SL brackets was statistically significant (P <0.0001). Seven percent of practitioners even reported using intervals of ten or more weeks for SL brackets. One orthodontist commented, SL brackets are better for patients that need longer intervals between appointments, such as college students, those that live far away, or those who simply have difficulty getting to appointments. However, one should keep in mind that longer appointment intervals could also result in longer treatment time. In fact, one practitioner who preferred SL brackets and has used them for over five years stated, I do not use the extended intervals; that did not work for me; treatment time was extended. The results of this study indicated a significant relationship between an orthodontist s appointment intervals and their bracket preference. More specifically, practitioners who reported longer intervals with conventional brackets were more likely

31 21 to indicate that patients experience less discomfort during adjustments with conventional rather than SL brackets. These practitioners also indicated that conventional brackets were more cost effective than SL brackets, and they were more likely to prefer conventional brackets during the finishing and detailing stages of treatment. On the other hand, practitioners who reported longer appointment intervals with SL brackets were more likely to prefer SL brackets for the majority of the treatment factors, including faster initial treatment progress, better oral hygiene, shorter adjustment appointments, and an overall shorter treatment time in comparison with conventional brackets. Even with longer appointment intervals for SL brackets, however, these practitioners were not more likely to indicate SL brackets as being more cost effective than conventional brackets. In this study, 36% of orthodontists discontinued use of SL brackets after their experience with these brackets. Of those orthodontists, 59% reported this decision was primarily the result of not observing significant enough advantages with SL brackets to justify expansion of inventory and increased cost associated with these brackets. One orthodontist stated, The price difference is ridiculously high and the advantages are nonexistent, while another remarked, The economy has resulted in a drop in starts and exams, and the cost of self-ligating is too high! In addition, 34% of orthodontists who have discontinued use reported they were able to achieve better results with conventional brackets, and 18% simply did not like working with SL brackets clinically. Several practitioners stated, Disengagements near finishing actually made me less efficient, SL brackets don t rotate incisors well at all, and There is less control, detailing is more difficult, and some cases take longer than two years due to poor finishing. Several orthodontists also claimed they stopped using SL brackets because patients did not like

32 22 them, with one stating, My patients, especially the younger patients, all wanted colored ties. While the arguments against SL brackets were made clear by many orthodontists, SL brackets were still found to be statistically significantly preferred by responding practitioners for the majority of the treatment factors presented in the survey. In particular, this preference for SL brackets was found to be most apparent for three factors: shorter adjustment appointments, faster initial treatment progress, and preferred ligation method during the initial alignment stage of treatment. The original motive for developing SL brackets was to speed the process of ligation. 1 When asked which brackets have shorter adjustment appointments, 64% of orthodontists indicated SL brackets, whereas, only 7% indicated conventional brackets. This revealed a strong statistically significant preference for SL brackets when considering the length of adjustment appointments and a potential reduction in chair time. An orthodontist remarked, I use SL brackets to make each appointment more efficient. I can adjust and change archwires faster with these brackets. Previous studies have reported reductions in archwire changes ranging from 25 seconds per arch to 2 to 3 minutes per patient using SL brackets compared to elastomeric ligatures. 7,14,38,39 This increased efficiency is much more apparent when compared to the use of steel ligatures, with time savings of 10 to 12 minutes per patient. 38 On average, most literature indicates that self-ligation results in a modest, yet consistent, reduction in chair time. 53 One study indicated the reduced chair time with SL brackets rather than elastomeric ligatures could save an average of one hour per day. 38 Others pointed out that the modest time savings from the archwire changes represents only a small fraction of the actual chair time during an orthodontic treatment visit. 37 Therefore, it is ultimately up to each individual

33 23 practitioner to determine if this is a significant contribution to the efficiency of their practice. When considering the effect of bracket type on adjustment appointments, one must also evaluate the bracket preference of the assistants, who often are responsible for much of the archwire and bracket handling during these appointments. In this study, only 19% of orthodontists perceived that their assistants did not have a bracket preference. Furthermore, 33% of respondents claimed their assistants preferred conventional brackets and 49% SL brackets. Even though this evaluation is somewhat inadequate, since assistants were not directly surveyed, the results showed a slight preference for SL brackets. Regardless, it is likely for an assistant to simply prefer the bracket type with which they are most familiar. One orthodontist commented, This question (assistant bracket preference) is tough because my assistants have used conventional brackets for many years, while another simply stated, My staff hated SL brackets. A different practitioner remarked, I like SL brackets since they make each assistant equal in their ability to engage the brackets. In addition to providing shorter adjustment appointments, orthodontists also noted a strong preference for SL brackets when asked which bracket they thought produced faster initial treatment progress, and therefore additionally preferred this ligation method during the initial alignment stage. Sixty-six percent of practitioners perceived initial treatment to progress faster with SL brackets, compared to only 3% who chose conventional brackets. Likewise, 68% of practitioners indicated a preference for SL brackets during the initial alignment stage of treatment, compared to 18% who preferred conventional brackets for this stage. There was also a significant preference for SL

34 24 brackets during space closure and anterior-posterior changes. For this stage of treatment, 54% of practitioners preferred SL brackets and 28% preferred conventional brackets. These reported treatment preferences for SL brackets corresponded with one of the most purported advantages of self-ligation: reduced friction between the archwire and the bracket along with more secure full bracket engagement which, therefore, permits rapid alignment and more certain space closure with excellent control of tooth position. 1,2 These results were conveyed by some orthodontists who stated, My rotations work out faster with SL brackets, and I prefer SL in extraction and space closure cases due to better sliding because of less friction. On the other hand, several practitioners stated, I simply haven t seen the considerable difference that is always discussed that SL brackets are faster in initial alignment than conventional, and SL brackets have significantly more problems correcting rotations, especially with mandibular incisors, which slows the first stage of treatment. A recent systematic review reported that currently, prospective research considering the efficiency of orthodontic alignment and rate of space closure has consistently shown little difference between SL and conventional brackets. 48 One of these studies found no overall difference between the two modes of ligation in the time required to resolve mandibular crowding. 25 Another study found no difference in the rate of en-masse space closure between passive SL brackets and conventional brackets. 30 These findings are not in agreement with some retrospective studies, 7,24 and with manufacturers claims of superior clinical performance in moving teeth with SL brackets. 48 Multiple in vitro studies have clearly shown SL brackets to generate significantly lower frictional forces than conventional brackets when archwires are slid in a passive configuration. 5,13-19 However, when considering the previously mentioned studies

35 25 revealing no difference between bracket types for alignment efficiency and space closure, it becomes apparent that other components, besides just friction, must impact these treatment factors as well. In orthodontic tooth movement, if a bracket could be held steady in a passive configuration to the archwire, classic friction, which has been reported to be less with SL brackets, would be the only component of resistance to sliding or movement. 54 However, this condition never occurs clinically since the bracket, along with the tooth, tips relative to the archwire when a force is applied to move it. When this tipping reaches a specific angulation, known as the critical contact angle, the archwire contacts the corners of the bracket and binding occurs, which then contributes to the resistance to sliding. 23 This critical contact angle for brackets has been found to range from approximately 3 to 5 degrees, and as this angulation increases, binding increases and quickly becomes the major source of resistance to sliding while friction becomes insignificant. 23 At an even greater contact angle, notching of the archwire occurs which resists movement until released from contact with the bracket, and both friction and binding become negligible. 23 Clinical studies have shown that the binding and releasing phenomenon, not frictional resistance, is the major determinant of how well teeth move along an archwire, 23 especially during initial alignment when large contact angles resulting from malposed teeth are encountered. Furthermore, several studies have concluded that binding and notching are independent of ligation method and, therefore, are the same regardless of the bracket type used. 23,54,55 If this is the case, there should be no difference in tooth movement during initial alignment and space closure between the two bracket types.